Provider Demographics
NPI:1215974233
Name:WELLS, GROVER ASHTON III (MD)
Entity type:Individual
Prefix:
First Name:GROVER
Middle Name:ASHTON
Last Name:WELLS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1202
Mailing Address - Country:US
Mailing Address - Phone:334-222-4191
Mailing Address - Fax:334-222-9069
Practice Address - Street 1:125 MEDICAL PARK DR
Practice Address - Street 2:SUITE 106
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5316
Practice Address - Country:US
Practice Address - Phone:334-222-4191
Practice Address - Fax:334-222-9069
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51097094OtherBLUE CROSS BLUE SHIELD AL
AL009926920Medicaid
AL51094943OtherBLUE CROSS BLUE SHIELD AL
AL000097094Medicare ID - Type Unspecified
ALH14797Medicare UPIN
AL000094943Medicare ID - Type Unspecified